SAN FRANCISCO – Palliative care is not just for the dying.
Understanding that premise is the first step to integrating palliative care into intensive care units, Dr. Zara Cooper said. Palliative care treats patient illness and can be delivered concurrently in the ICU with curative care that treats disease.
As options for curative treatment decrease, the role of palliative care may increase and does not stop at the patient’s death. "It’s important that we provide ongoing bereavement support not only to family members and survivors but also to caregivers and members of our medical team," added Dr. Cooper, an assistant professor of surgery at Harvard Medical School and a surgical intensivist at Brigham and Women’s Hospital, Boston.
Getting intensive care colleagues to agree on a definition of palliative care is the first barrier to integrating palliative care into an ICU, Dr. Cooper said. She paraphrased the World Health Organization’s definition by saying, "Palliative care makes patients feel better." It is specialized medical care that focuses on preventing and relieving symptoms, pain, and stress associated with life-threatening illness – whatever the diagnosis – and is appropriate at any stage in a serious illness.
Typically provided by a team, palliative care may involve physicians, nurses, social workers, pharmacists, chaplains, pain experts, ethicists, rehabilitation therapists, psychiatry consultants, and bereavement counselors. The team can take a load off busy intensivists by handling the often lengthy conversations with patients and families facing life-threatening illness, she said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
Palliative care providers can be embedded in ICUs or in a team that’s available as consultants. "I think we have to do both" models, depending on the needs of individual institutions, said Dr. Cooper.
Once a definition is agreed upon, the next steps to convincing colleagues and administrators to make better use of palliative care are to make it relevant for them and to normalize its presence in the ICU, she said. "Palliative care is just as essential as med management, antibiotics, pharmacology – it’s part of what we do well."
Predicting which patients will die, and when, is difficult. Patient preferences for care or end-of-life treatment often are unclear. The goals of treatment depend on the patient’s condition and must be dynamic. "Is it end-of-life care if we don’t know the patient is dying?" she asked.
One way to consider which ICU patients might benefit from palliative care is to ask, "Would I be surprised if this patient died within a year?" even if discharged from the ICU or the hospital, she suggested.
Four studies in the medical literature separately reported that 20% of Americans die in the hospital after an ICU admission, 80% of deaths in ICUs occur after life support is withdrawn or withheld, nearly half of dying patients receive unwanted therapy, and a majority of dying patients experience pain and suffering, Dr. Cooper said. Five other studies reported high mortality rates in patients with sepsis, acute respiratory distress syndrome, ICU stays longer than 14 days, admission to long-term acute care, or initiation of dialysis in the elderly.
A recent study of 25,558 elderly patients undergoing emergency surgery reported 30-day mortality rates of 37% in those with preexisting do-not-resuscitate (DNR) orders and 22% in those without DNR orders. Major complications occurred in more than 40% in each group (Ann. Surg. 2012;256:453-61). Risk factors increase the likelihood of death, but "all of these patients are experiencing serious illness" and would benefit from palliative care, Dr. Cooper said.
One recent study of 518 patients in three ICUs found good adherence to only two of nine palliative care processes – pain assessment and management. Interdisciplinary family meetings had been held by day 5 in the ICU for less than 20% of patients, and adherence to six other palliative care practices ranged from 8% to 43% (Crit. Care Med. 2012;40:1105-12).
Normalizing palliative care in the ICU means adopting the attitude that "it’s just part of what we do, the same way that we manage our vents, etc." Dr. Cooper said.
Adopting proactive screening criteria (patient factors) that trigger palliative care consultations would reduce utilization of ICUs without increasing mortality, and would increase the availability of palliative care for patients and families, according to a recent report from the Improving Palliative Care in the ICU Project’s advisory board (Crit. Care Med. 2013;41:2318-27).
The triggers should be specific to each ICU and patient population and developed through a process with stakeholders, with outcomes evaluated. "This is not a one-size-fits-all strategy," Dr. Cooper said. "The triggers in the MICU [medical ICU] and the SICU [surgical ICU] cannot be the same. It won’t work. I’ve actually seen that in my own institution," Dr. Cooper said.